Cause-specific mortality risk stratification in maintenance hemodialysis: a comparative analysis of infection-related versus cardiovascular-cerebrovascular death

doi:10.3877/cma.j.issn.1674-0785.2025.09.006

Abstract

Abstract:

Background

Maintenance hemodialysis (MHD) is the principal renal-replacement modality for end-stage renal disease in China, yet mortality remains high and heterogeneous. We aimed to delineate differential risk factors for infection-related versus cardiovascular-cerebrovascular death and to develop cause-specific prediction tools.

Methods

In this single-centre retrospective cohort, 164 MHD inpatients who died between 2020 and 2025 in Peking University Shougang Hospital were stratified into either an infection death group (n = 56) or a cardiovascular-cerebrovascular death group (n =108). Demographics, laboratory indicators, (ALB, PA, CRP, PTH, and β₂-microglobulin), and dialysis adequacy (kt/v) were collected. Multivariable logistic regression was used to identify independent predictors, and a joint nomogram incorporating gender, kt/v, PTH, β₂-microglobulin, and CRP was constructed. Model performance was evaluated by ROC, calibration, and decision-curve analyses.

Results

Among the 164 patients included, infection death (n=56) and cardiovascular-cerebrovascular death (n=108) differed significantly: females were more prevalent in the cardiovascular death group (48% vs 29%; P=0.016), while CRP levels were higher in the infection death group [(116.5±113.3 vs 76.4±71.8) mg/L; P=0.006]. Multivariable logistic regression showed that infection death was independently associated with female gender (odds ratio [OR]=0.20, 95% confidence interval [CI]: 0.08~0.52), CRP elevation (OR=1.006 per 1 mg/L), kt/v ＜ 1.2 (OR=12.71), and lower PTH (OR = 0.996 per 10 pg/ml). Cardiovascular-cerebrovascular death was driven by female gender (OR=4.95, 95%CI: 1.93~12.69), reduced kt/v (OR = 0.92 per 0.1 increment), elevated PTH (OR = 1.004 per 10 pg/ml), elevated β₂-microglobulin (OR=1.047 per 1 mg/L), and lower CRP (OR = 0.994 per 1 mg/L). The joint model achieved an area under the ROC curve of 0.757 for cardiovascular-cerebrovascular death, with good net clinical benefit across 10~70% risk thresholds.

Conclusion

MHD patients exhibit distinct risk profiles for infection versus cardiovascular -cerebrovascular mortality. The validated cause-specific nomogram enables rapid, individualized risk stratification and targeted preventive strategies.

Key words: Maintenance hemodialysis, Infectious death, Cardiovascular cerebrovascular death, Risk prediction, Nomogram

Chao Wang, Xiaohui Zhang, Xiaofan Li, Haidan Zhao. Cause-specific mortality risk stratification in maintenance hemodialysis: a comparative analysis of infection-related versus cardiovascular-cerebrovascular death[J]. Chinese Journal of Clinicians(Electronic Edition), 2025, 19(09): 675-681.

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Figures/Tables 5

死因分组	因感染死亡（56例）	因心脑血管疾病死亡（108例）	P值
收缩压（mmHg， $x ¯$ ±s）	131.25±30.18	122.45±31.65	0.088
舒张压（mmHg， $x ¯$ ±s）	66.48±13.11	64.30±15.92	0.378
白蛋白（g/L， $x ¯$ ±s）	32.14±4.65	31.86±5.20	0.731
血红蛋白（g/L， $x ¯$ ±s）	92.91±18.83	93.24±21.13	0.922
前白蛋白（g/L， $x ¯$ ±s）	0.16±0.10	0.14±0.08	0.081
C反应蛋白（mg/L， $x ¯$ ±s）	116.51±113.29	76.39±71.81	0.006
钙（mmol/L， $x ¯$ ±s）	2.08±0.21	2.06±0.24	0.619
磷（mmol/L， $x ¯$ ±s）	1.97±0.72	2.02±0.73	0.675
钙磷乘积（mmol²/L²， $x ¯$ ±s）	4.12±1.60	4.21±1.73	0.752
甲状旁腺激（pg/ml， $x ¯$ ±s）	183.07±109.12	251.11±252.35	0.056
β2微球蛋白（mg/L， $x ¯$ ±s）	31.90±9.70	35.29±11.39	0.059
死亡年龄（岁， $x ¯$ ±s）	68.84±9.87	65.30±12.72	0.071
透析时长（月， $x ¯$ ±s）	44.64±41.78	56.13±43.73	0.107
透析充分率（ $x ¯$ ±s）	1.28±0.25	1.22±0.21	0.108
性别[例（%）]			0.016
男性	40（71.43）	56（51.85）
女性	16（28.57）	52（48.15）
并发症个数[例（%）]			0.743
≤2	16（28.57）	25（23.15）
3	27（48.21）	57（52.78）
4	13（23.21）	26（24.07）
是否合并糖尿病[例（%）]			0.857
否	22（39.29）	44（40.74）
是	34（60.71）	64（59.26）

死因分组	因感染死亡（56例）	因心脑血管疾病死亡（108例）	P值
收缩压（mmHg， $x ¯$ ±s）	131.25±30.18	122.45±31.65	0.088
舒张压（mmHg， $x ¯$ ±s）	66.48±13.11	64.30±15.92	0.378
白蛋白（g/L， $x ¯$ ±s）	32.14±4.65	31.86±5.20	0.731
血红蛋白（g/L， $x ¯$ ±s）	92.91±18.83	93.24±21.13	0.922
前白蛋白（g/L， $x ¯$ ±s）	0.16±0.10	0.14±0.08	0.081
C反应蛋白（mg/L， $x ¯$ ±s）	116.51±113.29	76.39±71.81	0.006
钙（mmol/L， $x ¯$ ±s）	2.08±0.21	2.06±0.24	0.619
磷（mmol/L， $x ¯$ ±s）	1.97±0.72	2.02±0.73	0.675
钙磷乘积（mmol²/L²， $x ¯$ ±s）	4.12±1.60	4.21±1.73	0.752
甲状旁腺激（pg/ml， $x ¯$ ±s）	183.07±109.12	251.11±252.35	0.056
β2微球蛋白（mg/L， $x ¯$ ±s）	31.90±9.70	35.29±11.39	0.059
死亡年龄（岁， $x ¯$ ±s）	68.84±9.87	65.30±12.72	0.071
透析时长（月， $x ¯$ ±s）	44.64±41.78	56.13±43.73	0.107
透析充分率（ $x ¯$ ±s）	1.28±0.25	1.22±0.21	0.108
性别[例（%）]			0.016
男性	40（71.43）	56（51.85）
女性	16（28.57）	52（48.15）
并发症个数[例（%）]			0.743
≤2	16（28.57）	25（23.15）
3	27（48.21）	57（52.78）
4	13（23.21）	26（24.07）
是否合并糖尿病[例（%）]			0.857
否	22（39.29）	44（40.74）
是	34（60.71）	64（59.26）

因素	Estimate	SE	HR值	95%CI low	95%CI upp	P值
截距	-11.20219	6.27123	0.00001	0	2.97254	0.074053
性别（女性）	-1.59866	0.48057	0.20217	0.07882	0.51854	0.000879
收缩压（mmHg）	0.01292	0.00933	1.01301	0.99466	1.03169	0.165848
舒张压（mmHg）	-0.02401	0.02034	0.97628	0.93813	1.01598	0.237839
血红蛋白（g/L）	-0.00434	0.01112	0.99567	0.97421	1.01761	0.696364
白蛋白（g/L）	-0.03615	0.05597	0.9645	0.86429	1.07633	0.518399
前白蛋白（g/L）	5.71888	3.11767	304.56416	0.67587	137244.8343	0.066603
C反应蛋白（mg/L）	0.00577	0.00234	1.00579	1.00119	1.0104	0.013535
钙（mmol/L）	5.3111	2.96475	202.57331	0.60665	67643.70428	0.073226
磷（mmol/L）	3.77762	2.84091	43.71196	0.16687	11450.62924	0.183609
钙磷乘积（mmol²/L²）	-1.8265	1.36481	0.16098	0.01109	2.33621	0.180805
甲状旁腺激（pg/ml）	-0.00437	0.00205	0.99564	0.99166	0.99964	0.032816
β2微球蛋白（mg/L）	-0.04565	0.02175	0.95537	0.9155	0.99698	0.035827
透析充分率	2.54269	1.0643	12.71378	1.57879	102.38261	0.016891
并发症个数	-0.57197	0.5236	0.56442	0.20225	1.57507	0.274674
透析＞5年	-0.12404	0.49238	0.88334	0.33652	2.31874	0.801098

因素	Estimate	SE	HR值	95%CI low	95%CI upp	P值
截距	11.202 19	6.271 23	73 290.8730 6	0.336 41	inf.	0.074 053
性别（女性）	1.598 66	0.480 57	4.946 39	1.928 49	12.687	0.000 879
收缩压（mmHg）	-0.012 92	0.009 33	0.987 16	0.969 28	1.005 37	0.165 848
舒张压（mmHg）	0.024 01	0.020 34	1.0243	0.984 27	1.065 95	0.237 839
血红蛋白（g/L）	0.004 34	0.011 12	1.004 35	0.9827	1.026 48	0.696 364
白蛋白（g/L）	0.036 15	0.055 97	1.036 81	0.929 09	1.157 02	0.518 399
前白蛋白（g/L）)	-5.718 88	3.117 67	0.003 28	0.000 01	1.479 58	0.066 603
C反应蛋白（mg/L）	-0.005 77	0.002 34	0.994 25	0.9897	0.998 81	0.013 535
钙（mmol/L）	-5.3111	2.964 75	0.004 94	0.000 01	1.6484	0.073 226
磷（mmol/L）)	-3.777 62	2.840 91	0.022 88	0.000 09	5.992 79	0.183 609
钙磷乘积（mmol²/L²）	1.8265	1.364 81	6.212 11	0.428 04	90.155	0.180 805
甲状旁腺激（pg/ml）	0.004 37	0.002 05	1.004 38	1.000 36	1.008 42	0.032 816
β2微球蛋白（mg/L）	0.045 65	0.021 75	1.046 71	1.003 03	1.0923	0.035 827
透析充分率	-2.542 69	1.0643	0.078 65	0.009 77	0.6334	0.016 891
并发症个数	0.571 97	0.5236	1.771 75	0.634 89	4.944 27	0.274 674
透析＞5年	0.124 04	0.492 38	1.132 07	0.431 27	2.971 63	0.801 098

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